Watchman Procedure

Anesthesia Implications

Position: Supine, arms tucked
Time: 2-4 hours (long)
Blood Loss: Low (10-50 ml)
Maintenance Paralytic: No
Lead: Yes

The Watchman is also known as the Left Atrial Appendage Closure Device (LAACD)

Contraindications to watchman placement – Thrombus is visualized by transesophageal echocardiogram (TEE). Echocardiogram will be performed as a part of the procedure prior to placement of the watchman device.

Afib – Patients requiring a watchman device will have atrial fibrillation and potentially other heart/lung diseases.

Arterial line – Arterial line placement is necessary due to the risk of cardiac perforation, pulmonary artery or vein damage, or hemodynamic instability due to blood loss. An arterial line is also helpful for blood draws intraoperatively while monitoring ACT levels after heparin boluses are given.

Large-bore IV – One large bore IV is usually sufficient, but some anesthesia providers choose to place a second IV as a precaution.

Deep extubation – Deep extubation is recommended (if not contraindicated) to minimize coughing/ straining at the femoral guide wire insertion site.

Postoperative tamponade – If tamponade occurs (unlikely), avoid the use of phenylephrine to correct pressures. Use ephedrine or epinephrine. If absolutely necessary, the venous introducers at the groin can be utilized to give fluids. Protamine will be used to reverse the heparin (1 mg/100 u of Heparin previously administered. Give SLOWLY). Blood removed via pericardiocentesis will be reinjected via the femoral line. If bleeding persists (doesn’t clot) an emergency repair of the perforated atrium will have to be performed.

Overnight stay – After these procedures, patients are typically monitored overnight.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.

Patients requiring a watchman procedure will be diagnosed with chronic atrial fibrillation and are potentially unable to take blood thinners on a long-term basis. The left atrial appendage (LAA) is the primary site where blood clots can form, which can lead to a thromboembolic event.
For this reason, permanent closure of this appendage is prescribed by the watchman procedure. After this procedure, these patients should be able to decrease or even stop taking blood thinners over time.

The primary objective of this procedure is to permanently close the left atrial appendage (LAA).

Performed in the cath lab.

This procedure involves placing a TEE probe (either by a trained anesthesia provider or cardiologist). Once the heart is visualized, the surgeon will place a guide wire through the femoral vein to the heart. Once the guide wire has been successfully placed at the LAA, the Watchman device is deployed to seal it off.